Diagnosis & Stage screen in MOSAIQ 2.2

 

The Diagnosis and Staging screen is a real step backwards in functional use since v4.0, AND to boot is well behind the functionality that could accompany the screens.

There are several problems, and I approach this from the stance that I only have my system to use. All the actions I describe are being undertaken real time as I describe them, so you will need to run your copy of our version to see what I am doing :

  1. lack of keyboard support

while there are people who cannot operate without a mouse, the typing paradigm remains strong, and is getting more prevalent the predictive text in phone/tblet use. While it is possible to navigate the D&S screen with the keyboard, this is ONLY if you have a set of parameters which will work first time, and you happen to know where the selection is going next. (I still haven't managed to reach the TNM section yet!)

Lets move through the fields individually:

DIAGNOSIS 

if you enter 'c32', the correct drop down list appears, but the down arrow key does not move through the selections

if you enter 'adrenal', there is no list, just top directory saying "Group ICD10 AM - ALL"; if I type in 'lung', I get the top directory I get get the top directory again, BUT if I type in 'bronchus', I get the correct drop down. When I am after "C34 Malignant neoplasm of bronchus and lung", I don't understand the reason for the difference, particularly as 'lung' is more commonly used than 'bronchus'

MORPHOLOGY

the 'old' system of selection still exists in MOSAIQ under the Follow up screen. If you go there to select the morphology "adenocarcinoma, NOS", you can experience this.

 

I enter 'adeno' press TAB, TAB, then hit the down arrow 5 times and press ENTER, and I have my selection. For 'infiltrating duct carcinoma, NOS', I do the same thing but use the down arrow key 9 times.

In the 'new' system, if I enter 'adeno', I get a blank dropdown. If I type in 'adenoc', I get a listing of 10 directories. Same for 'adenocarcinoma'. 'Adenocarcinoma, NOS' gets me 3 directories, but 'adenocarcinoma, NOS' followed by TAB gets me "8140/3 00 Adenocarcinoma, NOS" - which is what I want! So I am tempted to think that if I type the full text correctly, I'll be able to TAB to the next field.

BUT ....

I enter 'duct' and I get 3 directories. If I type in "infiltrating duct carcinoma, NOS", which is the exact text for what I want and press TAB, I get "8500/2 00 Intraductal carcinoma, non-infiltrating, NOS". If I don't press the TAB, then I can see 4 choices, some of which are not very similar to my exact entry. 

Need I say more?? The original pattern makes for rapid approximate searching without using a mouse. Getting adenocarcinoma gets entered in less than 2-3 seconds. In the new system I MUST go for the mouse.

CONFIRM

when I click on the blank entry, nothing happens

HP GRADE

when I click on the blank entry, something happens - the drop down list appears (why not the same as Confirm? Please change the Confirm if you change anything!).

options 5-8 are not consistent with the oncological category "Grade". Whoever told you to put diagnostic categories there is just plain wrong. If you have a field called "Speed of Travel", the choices are 'fast', 'slow', 'very slow' and 'propeller', I'm sorry but the last one is wrong.

I understand the desire for others to want to record things, but the fields have to be consistent with oncological knowledge

hijacking by non-oncologist interests

  1. Grade/Differentiation drop downs
    Options 5-8 are obviously requested by Cancer registries and are not relevant for oncological grading. It should be consistent and sufficient for the oncologist who is the user of this screen. If Cancer registries want their own screens, build them somewhere else, but if they are going to use the oncologists screen then they use them as oncologists would. If haematologists requested the change then shame on them for their non-oncological categories. Options 5-8 are included in the morphology section.
  2. Collaborative Staging tab
    If some else feels the need to enter data, but the clutter somewhere else. It is distracting for the oncologist.
  3. added drop downs that can't be removed
    1. Grade/Differentiation drop downs 
      these cannot be altered to scrub options 5-8 which are not relevant for staging. It should be consistent and sufficient for the oncologist and incapable of change, or a free-for-all and capable of change.

  4. fields without explanation
    1. [Details:Basis]
    2. [Details:Last Follow Up]
      what does this mean? The last time I saw the patient? The last time I will see the patient? Surely the former comes from the appointment schedule, and the alter comes from the status saying Inactive? Either way, its use is fuzzy. Furthermore, why is it in the D&S screen which belongs to the oncologist?
    3. [Details:Decision to Treat]
      Shouldn't that be the date that the CarePlan was created?
    4. [Details:Urgent GP Referral]
      I can't imagine what this might be used for.
    5. [Tumor:Specimen Nature]
      I can't imagine what this might be used for.
      [Tumor:Synchronous Tumour Indicator]
      I can't imagine what this might be used for.
    6. Add Tumor.. functionality
      is this the primary, nodes or metastases being described? The freehand text description means that there will be an indecipherable series of options. This add-on functionality is not linked as it should be, i.e., to a T, N or M entry. The issue of multiple primary lesions as occurs in the breast is relevant here but because there is no tick box for multiple primaries, there is no option to trigger a call to pull this section open to ask for completion.
  5. Field duplication between tabs
    1. [Staging:HP Grade] - [Details:Grade of Differentiation at Diagnosis] - [Collaborative Staging: Grade/Differentiation]
      which one is the correct one?
    2. [Staging:Confirm] - [Details:Basis]
      Confirm is a drop down menu and Basis is a text box, which is not similar, BUT when I think about what the word "Basis" could mean, I am struck that the questions "How was the cancer diagnosis CONFIRMed?" and "What was the BASIS of the cancer diagnosis?", the answer "By histopathology" seems to fit both.
    3. Tumour Markers : Diagnosis Specific Values
      aren't these the same things? For prostate, I enter PSA values in the DSV, and nothing in the TM section. How is TM supposed to be used. If it has been superceded by DSV, remove it from the screen.

Additional functionality

There are emerging changes particularly in staging at present. The notion of clinical V imaging (CT V MRI V PET) V pathological staging is getting quite detailed and complex. The basic problem is that you can assign a stage based on any of these visualisation techniques, but that we can record only one. People are starting to want to be able to assign each for independent analysis. (we had a case yesterday where two PET scans were done before treatment, one says 'metastatic' disease and the second says 'confined' disease. The notion that we throw away the data from the first is short-sighted. Certainly we should have a final summary TNM, but the underlying discovery process should still be there for discovery if wished. So a case might be coded 'pT2imT1icT3cT0 pN0imT0icT0cT0 imM0icM0cM0'. 

In terms of "Direct Extension" and "Distant Mets" (both on Tumor tab), consideration should be given to including anatomical terms from SNOMED or FMA for more accurate delineation of metastasis sites. Also Direct Extension is text entry and this makes differences like 'bladder' and 'blader' non-trivial. Distant Mets is confined to three choices, this restriction is unreasonable. Please give thought to how to code as much or as little about metastatic sites as you want. 

With regards to staging and tumors and direct extension, it might be useful to have a staging window where you assign TNM, but then are permitted to add tumor details for as many lesions as there are. Something like this:

T   - site - dimensions - direct extension
   |_ site - dimensions - direct extension (these sites restricted by the ICD10 C listing; direct extension sites can also be restricted if an ontology approach is used)

N   - site - dimensions - direct extension
   |_ site - dimensions - direct extension 
   |_ site - dimensions - direct extension (these sites restricted to nodal sites) 

M   - site - dimensions - direct extension
   |_ site - dimensions - direct extension 
   |_ site - dimensions - direct extension (these sites unrestricted) 

'Excision Margin' need some extension. There are two issues that need to be addressed - whether the resection is R0, R1, or R2 as well as a description of the margin distance (which should be close to the pathological staging area as it is intimately linked), and if involved, what extent of involvement.